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New Client Assessment Form

This confidential information and health history will not be released to any individual except when authorized with written consent or when required by law. Please complete this form as thoroughly as possible in order to provide a complete picture of your overall health.

Contact Information


Female
Male

Health Goals/Concerns


Diet Modification
Vitamic/Mineral Supplement
Herbs
Homeopathy

Medical History

Diet and Health Habits

Breakfast:

Lunch:

Dinner:


Smoke cigerettes
Drink alcohol
Drink coffee
Take recreational drugs

Client Agreement

By completing this form, you acknowledge that:

I understand that holistic nutrition is not covered by the provincial government (OHIP), though may be covered by private and extended insurance plans. Holistic nutrition may also be tax deductible.

I understand that working with a holistic nutritionist is a joint responsibility between me (the client), and the practitioner. Improving my lifestyle can be as important as the remedies and recommendations.

Informed Consent

I understand that holistic nutrition can be employed in conjunction with other forms of therapy and need not be considered exclusively beneficial. I acknowledge that working with other health care professionals will provide a more comprehensive and balanced wellness program.

I understand that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purpose of medical diagnosis, treatment, or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. Holistic nutrition does not substitute or replace routine medical visits, tests, or other medicines prescribed by other health care practitioners.

I recognize that even the gentlest forms of treatment potentially have their risks and complications. The risks associated with holistic nutrition include, but are not limited to, aggravation of pre-existing symptoms, allergic reactions to supplements or herbs, and interactions with prescription medications.

I voluntarily consent to work with an RHN and I intent for this consent form to cover my entire course of treatment with the RHN. I understand that I am free to withdraw my consent at any time.